KAFO

Legacy form will be accepted until Nov 1st. Access Legacy PDF work orders below:

KAFO METAL KAFO
Please do not print the Review page.

Scroll to the bottom, hit Complete and then download the work order.
KAFO

Intake Information
Patient ID:*

First InitialLast Name
PO or Encounter #:*
Clinician Name:*
Fabrication Location:*
Clinician Email:*
Please enter to receive confirmation.
Clinician Phone Number:*
Please enter a valid phone number.
Requested In-Office Date:

MonthDayYear
Date
Daily HFN Capacity
External
Return Shipping Method:

Ground2-dayPriority OvernightFirst OvernightLocal CourierPick up
Return Shipping Method:*
Shipping is same as Billing Address:*

YesNo
Bill to PCC#:*
Ship to PCC#:*
Ship to Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bill to Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bill to Address:*
Today's Date:*

MonthDayYear
Date

KAFO

Configurator
Please indicate measurement unit:*

incm

Measurements:
Left - Selection
Right - Selection
L - Finished Lateral Height: *
Decimal value optional
R - Finished Lateral Height: *
Decimal value optional
Finished Lateral Height - Container:
L - Finished Medial Height: *
Decimal value optional
R - Finished Medial Height: *
Decimal value optional
Finished Medial Height - Container:
L - Proximal Thigh Circ:*
Decimal value optional
R - Proximal Thigh Circ:*
Decimal value optional
Proximal Thigh Circ - Container:
L - Proximal Thigh ML:*
Decimal value optional
R - Proximal Thigh ML:*
Decimal value optional
Proximal Thigh ML - Container:
L - Distal Thigh Circ:*
Decimal value optional
R - Distal Thigh Circ:*
Decimal value optional
Distal Thigh Circ - Container:
L - Distal Thigh ML:*
Decimal value optional
R - Distal Thigh ML:*
Decimal value optional
Distal Thigh ML - Container:
L - Knee Center to Floor:*
Decimal value optional
R - Knee Center to Floor:*
Decimal value optional
Knee Center to Floor - Container:
L - Knee Center ML:*
Decimal value optional
R - Knee Center ML:*
Decimal value optional
Knee Center ML - Container:
L - Calf Height:*
Decimal value optional
R - Calf Height:*
Decimal value optional
Calf Height - Container:
L - Calf Circ:*
Decimal value optional
R - Calf Circ:*
Decimal value optional
Calf Circ - Container:
L - Calf ML:*
Decimal value optional
R - Calf ML:*
Decimal value optional
Calf ML- Container:
L - Distal Tip Medial Malleolus Height:*
Decimal value optional
R - Distal Tip Medial Malleolus Height:*
Decimal value optional
Distal Tip Medial Malleolus Height- Container:
L - Ankle ML:*
Decimal value optional
R - Ankle ML:*
Decimal value optional
Ankle ML - Container:
L - Met Head ML:*
Decimal value optional
R - Met Head ML:*
Decimal value optional
Met Head ML - Container:
L - Toe out˚:*
Degrees
R - Toe out˚:*
Degrees
Toe out˚ - Container:
L - Finished Footplate Length:*
Decimal value optional
R - Finished Footplate Length:*
Decimal value optional
Finished Footplate Length - Container:
L - Finished Lateral Height: *
Decimal value optional
R - Finished Lateral Height: *
Decimal value optional
L - Finished Medial Height: *
Decimal value optional
R - Finished Medial Height: *
Decimal value optional
L - Proximal Thigh Circ:*
Decimal value optional
R - Proximal Thigh Circ:*
Decimal value optional
L - Proximal Thigh ML:*
Decimal value optional
R - Proximal Thigh ML:*
Decimal value optional
L - Distal Thigh Circ:*
Decimal value optional
R - Distal Thigh Circ:*
Decimal value optional
L - Distal Thigh ML:*
Decimal value optional
R - Distal Thigh ML:*
Decimal value optional
L - Knee Center to Floor:*
Decimal value optional
R - Knee Center to Floor:*
Decimal value optional
L - Knee Center ML:*
Decimal value optional
R - Knee Center ML:*
Decimal value optional
L - Calf Height:*
Decimal value optional
R - Calf Height:*
Decimal value optional
L - Calf Circ:*
Decimal value optional
R - Calf Circ:*
Decimal value optional
L - Calf ML:*
Decimal value optional
R - Calf ML:*
Decimal value optional
L - Distal Tip Medial Malleolus Height:*
Decimal value optional
R - Distal Tip Medial Malleolus Height:*
Decimal value optional
L - Ankle ML:*
Decimal value optional
R - Ankle ML:*
Decimal value optional
L - Met Head ML:*
Decimal value optional
R - Met Head ML:*
Decimal value optional
L - Toe out˚:*
Degrees
R - Toe out˚:*
Degrees
L - Finished Footplate Length:*
Decimal value optional
R - Finished Footplate Length:*
Decimal value optional

KAFO

Notes
Your order will be sent to CDC after submission along with the Scan. No futher action is needed.

(No Entry required at the LEO portal)
Scan Upload:*

Accepted File types: med, fsn, op3, stl - 60 MB File Size Limit
Cancelof
Average Cast Thickness - Left (mm): *
Decimal Value Optional
Average Cast Thickness - Right (mm): *
Decimal Value Optional
Outside Cast Forefoot ML - Left (mm):*
Decimal Value Optional
Outside Cast Forefoot ML - Right (mm):*
Decimal Value Optional
Outside Cast Ankle ML - Left (mm):*
Decimal Value Optional
Outside Cast Ankle ML - Right (mm):*
Decimal Value Optional
Technical Consult: I would like a call to discuss prior to starting fabrication.

Yes
Who would you like a call from?*

Modifications (Modifier)Design options on device (Fab Supervisor)Shipping/Billing (Customer Support)
Technical Consult Team:
Notes:

0/250
Image upload (Optional):

Allowed Image types: jpg, jpeg, png, gif
Cancelof
Bilateral
- F0036
- F2600
- F0051
- F0052
- F2840
- F2850
- F2830
- F2860
- F2820
- F1915
- F0046
- F0040
- F0040
- F0028
- F3310
- F0046
- F0046
- F0047
- F0053
- F0023
- F5692
- F5692
- F0050
- F0050
- P1000
Raven Component Codes:
Lock Type:
Stirrup:
Ankle Joints:
Bars:
Posterior Stop:
- P9000
Should be Empty:

KAFO

KAFO

Device Design:

KAFO

Intrinsic Heel Skive requires external posting/wedging.

Knee Joints

Ankle Joints

Bar:

Plastic

Special Order Transfer Papers can increase device turnaround time.

KAFO